A New York DNR order is a written medical order. Under New York law, it directs emergency medical services, hospice, home care services agency and hospital emergency services personnel not to attempt cardiopulmonary resuscitation (CPR) if you suffer cardiac or respiratory arrest.[1.3] State law calls an order issued outside a hospital a nonhospital order not to resuscitate.[1.2] This free printable New York DNR form lets you record that choice. It covers CPR only, and other treatment choices are separate.
Last Updated: October 2026. This guide is reviewed and updated regularly to reflect current New York law. If you notice an error or outdated information, please contact us.
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A DNR order records one decision: you do not want CPR attempted if your heart stops or you stop breathing. CPR is a set of emergency measures meant to restart the heart or breathing. Patients often put the order in place before an emergency, while they can still talk it through with their doctor.
CPR includes these measures:
A DNR order covers CPR only. Choices about other treatment, such as medication, feeding tubes or blood transfusions, are separate. On the New York form they go in Section E.
For a version that is not tied to one state, see our printable DNR form.
New York law says a nonhospital order not to resuscitate must be issued on a standard form.[1.1] The attending practitioner must record it in your medical record, and you can revoke your consent at any time.[1.2]
In detail, the law says:
The revocation rule is worth reading in the statute's own words:
A person who has consented to a nonhospital order not to resuscitate may at any time revoke his or her consent to the order by any act evidencing a specific intent to revoke such consent.
In plain words, you can change your mind at any time. What counts is an act that shows you specifically intend to revoke your consent.
The attending practitioner is the physician, nurse practitioner or physician assistant who has primary responsibility for the patient's treatment and care.[1.4]
An adult with decision-making capacity, a health care agent or a surrogate may consent to a nonhospital order not to resuscitate, either orally to the attending practitioner or in writing.[1.5]
The attending practitioner must review whether the order is still appropriate each time they examine the patient, in the hospital or elsewhere, and at least every 90 days, though the review need not happen more than once every seven days.[1.6]
People choose a DNR order for personal reasons, and the decision is rarely easy. Some patients sign when they are very old or seriously ill and do not want CPR if their heart stops. Others decide earlier so that their wishes are on paper before an emergency.
Families may see the choice differently, so it helps to talk early. Before you decide, ask your doctor about:
You can change your mind later. New York law lets a person who consented to the order revoke that consent at any time.[1.2]
The New York DNR form is four pages long and has seven parts, from your personal details to Section F. The New York form is headed Medical Orders for Life-Sustaining Treatment (MOLST), so besides your DNR choice it holds orders about other treatment. Complete the parts in the order below.
Patient information. At the top of page 1, enter:
Section A: Resuscitation Instructions. Check one box.
Section B: Consent for Resuscitation Instructions. The decision-maker signs and dates this part. If consent was given verbally, check the verbal consent box and leave the signature line blank.
Print the decision-maker's name and the names of the two witnesses. Then check who made the decisions, such as the patient or a health care agent.
Section C: Physician, Nurse Practitioner or Physician Assistant Signature. A physician, nurse practitioner or physician assistant signs here for Sections A and B. They also print their name, the date and time, their license number and a phone or pager number.
Section D: Advance Directives. Check each advance directive that has been completed: a health care proxy, a living will, organ donation, or documentation of an oral advance directive.
Section E: Other Life-Sustaining Treatment. This part applies when the patient has a pulse and is breathing. It lists six groups of orders. Check one option in each of the first five, and use the last for anything not listed:
Below the orders, complete the consent block the same way as Section B. A physician, nurse practitioner or physician assistant then signs and prints their name and the date and time.
Section F: Review and Renewal. Leave this chart blank. It is where the clinician records each review of the orders and its result.
Each review is recorded with the date and time, the reviewer's name and signature, the location and the outcome: no change, form voided with a new form completed, or form voided with no new form.
The New York form is a State Department of Health form, DOH-5003. You can browse more in our New York State Department of Health forms collection.
These answers come from New York Public Health Law section 2994-dd, which governs a nonhospital order not to resuscitate. They cover what the order requires, what must be recorded in the medical record, and how a person who consented can revoke it.[1.2]
New York law sets these requirements for a nonhospital DNR order:
The attending practitioner must record the issuance of the order in the patient's medical record.[1.2] Keep your own copy of the signed order as well.
A person who consented to the order may revoke that consent at any time, by any act that shows a specific intent to revoke it.[1.2] Tell your doctor and your family when you do.
General information, not legal or tax advice.
The legal statements on this page rest on the New York Public Health Law provision listed below. Each numbered marker in the text points to the part of that law it comes from.
